1. LeeChuy, Katherine Lee, Sidney Abert Lerma, Daniel Joseph Legaspi, Roberto Jose Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold Lim, Mary Lim, Phoebe Ruth Lim, Syndel Raina Lipana, Kirk Andrew Liu, Johanna Llamas, Camilla Alay

2. Name: T. R. Age: 60 Sex: M Status: Married Nationality: Filipino Date of Birth: 12/10/1949 Place of Birth: Leyte Religion: Roman Catholic Eduacational attainment: High School Graduate Occupation: retired; former Government employee of Military Shrines Service Cu rrent Address: Sitio Libanan, Timbio Mariveles, Bataan Informant: Patient, Wife, Niece, Nephew Reliability: 70%

4. “Namamaga ang mga kasukasuhan sa paa, binti at kamay (swelling of the joints of the feet, legs and hands)”

5. 10 years PTA 5 years PTA -complained of joint pains and swelling -no limitation of movements -no consult was done; self-medicated with paracetamol 500mg + ibuprofen 200mg (alaxan), paracetamol (Biogesic) 500mg, Amoxicillin 500mg which provided slight relief -progression of swelling of both hands, elbows, knees and feet as noticed by the patient and the relatives - Persistent joint pain with limitation of movement -self-medicated with the previous drug plus some herbal medicines -patient sought consult at a local hospital where he was diagnosed to have “Gouty arthritis” -continued with his self-medicated drugs providing temporary relief 1 year PTA

6. 4 monthsPTA 2 weeks PTA -patient slipped off Mt. Samat which prompted admission to a local hospital in Bataan. -The patient claimed that he didn’t receive any wounds -He was confined and was placed under observation for 6 days He was relieved from the swelling through massaging “hilot”. -patient accidentally stepped on a sharp object causing a subsequent development of ulcer in the wound with some degree of scaling; clean the wound site with guava leaves and betadine and then would apply hydrogen peroxide with penicillin -recurrence of joint pain and swelling; self-medicated with Mefenamic acid 500 mg and amoxicillin 500 mg which provided relief

7. 1 week PTA -progression of joint pain and swelling, graded 10/10 With limitation of movement -the development of symptoms prompt consult on a private doctor ADMISSION (August 24, 2010)

8. General: no fever, no weight loss, (-)anorexia, (-) weakness, (-) insomnia HEENT: no blurring of vision, no eye redness, pain, itchiness, no excessive lacrimation, no ear pain nor tinnitus, no ear discharge, no epistaxis, no nose discharge, no anosmia, no obstruction nor sinusitis, no mouth sores, fissures, bleeding, no dental carries, no throat irritation, Pulmonary: no hemoptysis, no coughing, no dyspnea, no chest wall abnormality Gastrointestinal: (+) abdominal distention, no abdominal pain, no melena nor hematochezia, no changes in bowel habits Genitourinary: no hematuria, no dysuria, no urinary frequency, no hesitancy, no incomplete voiding Endocrine: no heat or cold intolerance, no polyphagia, no polydipsia, no polyuria, no thyroid enlargement Musculoskeletal: see HPI Hematologic: abnormal bleeding, no easy bruising

9. No major hospitalization, unrecalled immunizations No allergy, no previous transfusion (-) DM, PTB, Asthma, Cancer

10. Siblings - Arthritis (-) PTB, DM, thyroid disorders, Hypertension, cancer

11. Cigarette smoker since 10 years old (unrecalled number of sticks) Alcoholic beverage drinker ( 2 bottles; 3x a week and occasional gin drinker 2-3 bottles/week) Diet: mixed and prefers meat and vegetables Denies illicit drug use He left his home and has lost contact with his parents, brothers and sisters (he does not recall what age he was when he left)

13. General Survey: conscious, coherent, ambulatory, not in cardiorespiratory distress, normal speech, appropriate thought process and content and well- oriented as to time, place and date Vital Signs – Systemic BP: (RUE) 170/100 (LUE) 170/100 – PR: 74 beats/minute – RR: 17 cycles/minute – Temperature (axillary): 37.2 o C Anthropometric mesaurement -Ht: 5’1” Wt kg 71 kgs BMI: 29.9

14. Skin: Warm, moist skin, no active dermatoses, no jaundice HEENT: Pale palpebral conjunctivae, slightly icteric sclera, pupils ERTL 2-3mm, no exophthalmos, no tragal tenderness, no aural discharge, supple neck, no distended neck veins, no palpable cervical lymph nodes, thyroid gland not enlarged Pulmonary: Symmetrical chest expansion, no subcostal retractions, unimpaired tactile and vocal fremiti,(+) crackles on both lower lung bases, no wheezes, no rhonchi, resonant, clear breath sounds

15. Cardiovascular: Adynamic precordium, AB at 6 th LICS MCL, no heaves, no lifts, no thrills, S1>S2 apex,S2>S1 base; Pulses were full and equal in all extremities, (+) bipedal edema, no cyanosis and clubbing Gastrointestinal: flabby abdomen, (+) venous collaterals, normoactive bowel sounds, tympanitic upon percussion,no masses palpated, (+) shifting dullness, Traube’s space not obliterated, Liver span: 10cm,, (-) murphy’s sign abdominal circumferece:98 cm Genitourinary: (-) CVA tenderness

16. Musculoskeletal: deformed joints on the wrist, (+) swelling on the wrists to hands, ankles to feet, warm to touch Neurologic Exam Mental status: Conscious, awake, alert GCS 15 Pupils 2-3mm, isocoric ERTL, EOMs full and equal, no ptosis, no nystagmus No facial asymmetry, can shrug shoulders, can turn head against resistance MMT: 5/5 all extremities No sensory deficits Can do FTNT, APST with ease Reflexes: Superficial: (+) Gag and corneal reflex Deep Tendon: (++) on all extremities No Babinski, nuchal rigidity, Brudzinski, Kernig’s

17. Physical Examination

22. COMPLETE BLOOD COUNT*8/24Post- transfusion UNITREFERENCE RANGE Hemoglobin48117G/L120-170 RBCX 10^12/L4.0-6.0 HCT0.160.360.37-0.54 MCVU^387 + - 5 MCHPg29 + - 2 MCHC3032.50g/dl34 + - 2 RDW11.6 – 14.6 MPVfL7.4 – 10.4 PLATELET802450x 10^9 / L150 – 450 WBC19.88.50x 10^9 / L4.5 – 10.0 DIFFERENTIAL COUNT NEUTROPHILS0.890.800.50 – 0.70 METAMYELOCYTES0.01 BANDS0.010.00 – 0.05 SEGMENTED0.890.800.50 – 0.70 LYMPHOCYTES0.060.130.20 – 0.40 MONOCYTES0.020.00 – 0.07 EOSINOPHILS0.030.070.00 – 0.05 BASOPHILS0.00 – 0.01 *Peripheral smear : Hypochromic with anisocytosis and poikilocytosis

23. 8/24Reference Creatinine2.862.290.5-1.2 Sodium123132.48137-147mmol/L Potassium4.963.8-5mmol/L iPO44.52.3-4.7 mg/dL Intact PTH8.2 Ionized Calcium1.661.12-1.32 Fasting Blood Sugar 78.97 70-110 mg/dL BUN65.708-23 mg/dL SGPT36.913.8-5 U/L Uric Acid133.892.7-7.3

24. 8/24Reference Total Cholesterol 119.78 150-250 mg/dL Triglycerides130.33 10-90 mg/dL HDL22.03 LDL68.20 Total Protein7.00 6-7.8 g/dL Albumin2.57 3.2-4.5 g/dL Globulin4.43 2.3-3.5 g/dL HbA1c7.904.0-6.0

25. Other Ancillary procedures: Fecal occult blood test – (+) ECG – Sinus rhythm with left ventricular hypertrophy Urinalysis: albumin- negative, sugar – negative, RBC-0-2/hpf, Pus cell-1-4/hpf

26. SUBJECTIVE DATAOBJECTIVE DATA Age: 60 Sex: M Swelling of joints of hands, feet and legs Recurrent joint pains Limitation of movements Alcoholic beverage drinker Siblings- (+) Arthritis Diagnosed to have gouty Arthritis (+) swelling on the wrists to hands, ankles to feet, warm to touch Presence of joint deformities Presence of ulcers on the legs (+) Bipedal edema (+) Shifting dullness Abdominal circumference: 98cm (+) venous collaterals Slightly icteric sclerae Low Hgb and Hct on CBC with anisocytosis and poikilocytosis Increased BUN and creatinine SALIENT FEATURES

28. Present Medications Omeprazole 40 mg tab OD Amlodipine 10 mg tab OD Clindamycin 300 mg cap q 6 Ciprofloxacin 250 mg tab BID Given Colchicine as follows to treat acute gout: 2 tabs now then 1 tablet after 6 hours Cold compress x 10-15 mins TID on inflamed joints